Information or Therapy Request Form - Ellie Mental Health
Let’s find a therapist you vibe with! To get started, please complete this form to request a phone call where we’ll schedule your appointment. Sharing this info ahead of time will ensure you get matched more quickly with a therapist who really gets you (without spending unnecessary time on the phone).
Once your form is submitted, a member of our Team will call you within 1-2 business days.
By completing this form, you consent to have our team leave a voicemail, email or text offering more information. Caller ID and email address may show Ellie or Ellie Mental Health but no specific information regarding your request will be included within the voicemail, email or text.
Name
*
First Name
Last Name
Is the person seeking services a minor?
Yes
No
Sex
Please Select
Male
Female
Other
Phone Number
*
Please enter a valid phone number.
Email
*
example@example.com
Date of Birth
*
-
Month
-
Day
Year
Date
Do you have a preferred Ellie Mental Health location?
Please Select
Novi - 11 Mile Rd
West Bloomfield - Orchard Lake Rd
Please provide a brief summary describing your goals in therapy or the type of support or services you are seeking:
Do you have one of these insurances?
Aetna
ASR
Behavioral Health System
Blue Cross Complete
Blue Cross Network
BCBS
HAP
McLare
Medicare
Meritain Health
Multiplan
Optum (UHC/UMR)
Priority Health
Self-Pay
Tricare
None of the Above
Please verify that you are human
*
How did you hear about us?
*
Internet Search (Google)
Friend or Family Member
Another Provider (ie. Doctor, case manager)
An online advertisement (Facebook/YouTube)
At a Community Event (ie. resource fair, presentation)
Mailer
Other
Visit our Ellie Mental Health West Bloomfield Web Page
https://elliementalhealth.com/locations/west-bloomfield-mi/
Visit our Ellie Mental Health Novi Web Page
https://elliementalhealth.com/locations/novi-mi/
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